The role of the physician associate (PA) has been established in US healthcare since the 1960s.
It was first introduced in the UK in 2003,1 but is still thought of as a relatively new position and as a result remains confusing for many GPs – without prior experience of their scope of practice, considering employing a PA can seem like a step into the unknown.
The Royal College of Physicians’ formal definition is: ‘Physician associates are medically trained, generalist healthcare professionals, who work alongside doctors and provide medical care as an integral part of the multidisciplinary team.’2 A PA will have undertaken postgraduate medical training, generally over a two-year course, earning either a PGDip or MSc. During the course they spend time in a wide variety of clinic settings in primary and secondary care covering medical sciences, pharmacology and training in clinical reasoning. To complete their programme they must pass a national PA examination which standardises all the training programmes.
The main distinguishing factor separating PAs from other advanced care practitioners is their medically based training course, which allows them to effectively work to the same model as a GP, with a focus on assessment and diagnosis of acute undifferentiated and chronic conditions. Their sound background in pathophysiology and pharmacology potentially gives them greater ability to decipher complex medical presentations, without reliance on protocols. PAs are able to follow up their patients, interpret and act on investigation results and, with the correct guidance and training, telephone triage or home visiting is well within their competency.3
Once settled within their role, a PA may undergo further training to develop a special interest in an area such as contraception or joint injections, thereby freeing up valuable GP time and promoting increased job satisfaction and retention. As a fully involved member of the practice team, a progression into non-clinical roles is also expected, such as involvement in student teaching, quality improvement projects or taking a lead in a clinical area.
Given that PAs are a new breed of care practitioner, the current numbers in the workforce are small and relatively inexperienced. Therefore newly qualified PAs or those moving specialties will need close supervision, ideally by one dedicated GP, allowing for regular assessment and feedback during the early stages of their employment.
However, because of the large investment in the role, the numbers are likely to increase significantly in the coming years, providing a larger and more experienced pool of practitioners to recruit from.
The main drawbacks in terms of the PA’s scope of practice are their lack of ability to prescribe, and to request investigations involving ionising radiation. Currently PAs can formulate a management plan and propose a prescription, then ask a supervising GP for a signature.
You should timetable formal debriefing for discussion of cases, or for the GP to examine and review patients with the PA, similar to the training of a Foundation Year trainee.
The Government recently announced that the GMC will be responsible for regulating PAs and it is expected that prescribing rights will change once this regulation is introduced.4
Another issue can be resistance from certain patients in the move away from GP dominant healthcare teams and there will be a period of adjustment needed. Experience and studies shows that patients are on the whole receptive to new practitioners and there are comparable outcomes between GP and PA consultations.5
Because the GP workforce is declining and recruitment is increasingly difficult, many practices are choosing to or being forced to move away from the traditional ‘top-heavy’ GP model to an alternative system in which GPs are seen more in a supervisory role, working to oversee a team of advanced care practitioners and healthcare assistants. This is a major decision but one which must be considered in order to provide long-term security and sustainable practice.
For example, rather than looking at locums or salaried GPs, my practice has used the relatively lower-cost PAs to create a team to run a newly formed urgent care service, thereby freeing up GP time for longer routine appointments or for administration tasks. Before considering employing a PA, it is essential to ensure the practice or network has considered its long-term plan and whether the role may be better suited to a more established or alternative practitioner. Once a decision is made to employ a PA, there are generally two options available:
1. Become a training practice
There are over 30 university training programmes currently running nationally (see further reading section for more details) and all will require training in general practice. This is an excellent way to embrace PAs into your practice and develop a greater understanding of the benefits they could bring as a full-time employee, along with providing a new income stream. Clearly there are implications with this route in a financial sense and also workload pressures in allowing for supervision and training, and it must be seen as long-term gain rather than a short-term solution. However, with the correct training and clinical input, employing a PA following their qualification will mean they are already a key part of the practice team and be well prepared to take on a more independent role.
2. Employ a qualified PA
Adverts could be placed nationally or locally and it is definitely worth contacting any local university course directors to let them know you have a vacancy as they may be willing to advertise to graduating students directly. With the ongoing workload crisis in primary and secondary care, competent and experienced PAs are likely to be highly sought-after clinicians. It is important that adverts show your practice or network is keen to encourage career development, support and nurture existing skills and offer a competitive salary scheme.
Typical starting salaries are in the region of £30,000 with more experienced PAs expecting to earn between £33,000 and £49,000 according to the NHS Agenda for Change (AfC) pay scale.6 This is based on a 37.5 – 40-hour working week with suggested protected CPD time and puts them on a similar pay scale to other advanced care practitioners.
As mentioned above, it was recently announced that PAs will be regulated by the GMC, but it is advisable to check any potential employee is listed on the Physician Associate Managed Voluntary Register (PAMVR). Being on this register shows the PA has successfully completed the university programme and passed the PA national exam.
Funding is available through the Health Education England (HEE) preceptorship scheme, which provides £5,000 per annum – for a minimum of one year and usually offered for two years – to support the supervision and educational needs for newly qualified physician associates working in primary care in England. A number of local preceptorship schemes with additional funding incentives are available (contact your local HEE representative for further information).
As part of the 2019 GP contract and Network DES, the Additional Roles Reimbursement Scheme will cover Physicians Associates from 2020/21, funding up to 70% of a PA’s salary at Band 7 pay of AfC, for networks of up to 50,000 patients.
PAs working within a GP practice (whether employed directly or through a Network) will be covered for clinical negligence claims by the state-backed indemnity scheme, which was introduced from April 2019. As with GPs, additional coverage through a medical defence organisation may be advisable depending on the individual’s duties, such as providing cover against complaints or for extended roles.
Dr James Murray is a GP partner in York
There is a wealth of information available at the RCP Faculty of Physicians Associates website. This includes local contacts for HEE representatives who can be contacted for further information.
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